For those who don’t know, I’m living in Turkey at the moment and will be for another year to come. The reasons for this (as some of you know) are a combination of my husband’s work and to start a family. So I’m kind of on a career break (meaning I don’t work fulltime) but also keeping a foot in seeing patients when and where I can.

Now I could write a series of blogs, if not a book, about my experiences of seeing patients here…. they’re certainly many and varied and sometimes downright impossible - like the child I was taken to see to “make her walk” when she quite clearly had severe cerebral palsy and was already under a good medical team. I also get countless requests to look at elbows, give injections and make the lame walk! Podiatry is not well understood here and sometimes I feel like Dr Quinn: Medicine Woman!!

That said, it is a growing profession and one I hope to help develop in any way I can.

Anyway, I digress….. so, when I do get a request for my advice which does fall within my scope of practice, I’m more than delighted to get stuck in! A friend of a friend of ours is a professional basketball player who has a designated physio who understands a few podiatric principles. His problem was an ongoing Achilles pain which kept flaring up – I know I blogged about the Achilles last time but every case and every patient is different. For starters, this guy is a professional athlete not a weekend recreational runner, I’m not sure how true this is, but he told us that if he doesn’t play or they don’t win, they don’t get paid!

In last month’s blog, I used the term Achilles tendinopathy because I wasn’t 100% sure whether there was an inflammation. This time I was pretty sure it was a paratendinitis, or inflammation of the paratendon. According to Cohen and Balcon (2003) there is an area of relative avascularity which occurs between 2cm and 6cm proximal to its point of insertion into the calcaneous and this is where most problems occur. This certainly fitted with our athlete who was experiencing pain, swelling and warmth about 4 -5cm proximal to insertion. He also reported that while the problem came and went, it always tended to be worse towards the end of the winter season (before you ask – yes…. it does get very very cold in Turkey!)

Interestingly a prospective study by Milgrom et al (2003), looking at the risk factors for Achilles tendinopathy, found that 94% of infantry recruits who suffered with Achilles tendinopathy actually had a paratendinitis. They also found a significant increase of paratendinitis if training had taken place in the winter suggesting that the decreased temperature may increase the viscosity of the mucopolysaccharide which make up the paratendon membrane and serve as a lubricant. If this gliding of the tendon and epitendon is restricted, friction increases which could lead to a paratendinitis.

Essentially I was only really asked for advice with this guy but I thought it was an interesting case none the less. His Physio is very open-minded and keen on a multidisciplinary approach so we both learnt a few things from discussing his case. Achilles tendinopathy is one of the most common overuse injuries seen in sports medicine clinics according to Clement, et al (1984)…. old reference I know, but still the case! Most of us would agree that standard treatments may include activity modification, heel lifts, orthoses, stretching exercises, nonsteroidal anti-inflammatories, and eccentric loading. However, Wilson and Stacy (2011) suggest that the current body of research lacks a general consensus as to which conservative treatment is most effective. Conservative management certainly works for a lot of patients, but for some, it is inadequate.  One treatment which does seem to be gaining support is Extracorporeal shock wave therapy (ESWT). Various papers over the past few years have suggested this as a method for successfully treating Achilles tendinopathy and various other tendinopathies. Fridman, et al (2008) carried out a prospective study and concluded that ESWT was a safe, noninvasive, and effective treatment of chronic Achilles tendinopathy.

The warmer weather is coming now and our patient’s symptoms are improving. He’s still being closely monitored and our discussions are continuing. Our next step is likely to be looking at his foot mechanics, however, here’s some food for thought….

In the past, exercise regimes, eccentric and concentric loading, and muscle strengthening have all been key elements in the research regarding the treatment of tendinopathy. But this thought process looks set to change as new research is suggesting that we move away from this and focus on loading and then progressively loading the effected tendon as soon as possible while monitoring the patient’s pain. It all comes down to your specific patient and what they can tolerate. There are going to be some lectures and a fair bit of discussion on this at the 2016 Biomechanics Summer School in June, so definitely worth going along if you treat patients with tendinopathies – see you there J

 

References:

  1. Clement, D. et al. (1984) Achilles tendinitis and peritendinitis. Etiology and treatment. American Journal of Sports Medicine. (12) pp 179-184.
  2. Cohen, R. and Balcom, T. (2003) Current treatment options for ankle injuries: Lateral ankle sprain, Achilles tendonitis, and Achilles ruptureCurrent Sports Medicine Reports. 2(5) pp 251-254.
  3. Fridman, R. et al. (2008) Extracorporeal Shockwave Therapy for the Treatment of Achilles Tendinopathies. Journal of the American Podiatric Medical Association. 98(6) pp. 466-468.
  4. Milgrom, C. et al (2003) Cold Weather Training: A Risk Factor for Achilles Paratendinitis among Recruits Foot and Ankle International (24) pp 398-401
  5. Wilson, M. and Stacy, J. (2001) Shock Wave Therapy for Achilles Tendinopathy. Current Reviews in Musculoskeletal Medicine. 4(1) pp 6-10.